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(/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFr•-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 ��rcJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install, the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2 0 J l CENSUS TRACT ' <br /> Owner's Name Phone 3S - `oz�- <br /> Address9 �, h, City/ <br /> Contractor's Name icense # Phone <br /> D <br /> TYPE OF WORK (Check): NEW WELL '/1RDEEPEN -/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION fl/ PUMP REPAIR /� PUMP REPLACEMENT 17 <br /> Other j/% <br /> DISTANCE TO NEAREST: SEPTIC TANK = SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER * ] <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL / <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 0 <br /> I'idustrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing A <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal � <br /> Cathodic Protection Rotary Type of Grout B (A <br /> Disposal Other Other InformationAX w .res <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: . j//_ State Work Done <br /> PUMP ,REPAIR: /7 State Work Done - <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after, completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting.the..well. in.use... The above <br /> information is true to- the-best.af- my.knowledge and belief. I WILL CALL FOR A .GROUT INSPECTION <br /> PRIOR TO GROUTINr, AN FIN INS <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I .. <br /> APPLICATION ACCEPTED BY �., DATE ,-3 <br /> ADDITIONAL COMMENTS: <br /> PHASE 4L ff2UT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATES - INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 h/75 934 <br />